A review of the effectiveness of telemedicine in glycemic control in diabetes mellitus patients

This review aimed to evaluate the effectiveness of telemedicine as an intervention for patients with diabetes mellitus, considering blood glucose levels as the primary outcome. A comprehensive literature search was performed using the PubMed, Embase, Web of Science, and EBSCO databases. This narrative review covered randomized controlled trials published in English. The process of selecting studies adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines. Nine studies were selected, and their data were analyzed and summarized. Five of the nine reviewed studies found that telemedicine counseling was effective in decreasing glycated hemoglobin A (HbA1c) levels in the blood. Due to methodological limitations, one study could not report HbA1c results, and two studies reported that telemedicine counseling did not lead to any significant changes in HbA1c levels. One study found that while HbA1c levels did not show a marked decrease, patients’ treatment adherence and quality of life improved when telemedicine was combined with health counseling. Moreover, six studies found that telemedicine counseling was more effective than traditional counseling regarding secondary outcomes. The overall findings of this review suggest that telemedicine counseling is more effective than conventional counseling in achieving decreased blood glucose levels in patients with diabetes mellitus while increasing their treatment adherence and improving their quality of life.


Introduction
The global burden of diabetes mellitus (DM) and its prevalence continually increase. The global incidence of DM escalated by 102.9% between 1990 and 2017, rising from 11.3 to 22.9 million, with type 2 DM (T2DM) accounting for most cases. This trend is likely to continue to do so until 2025. In the absence of effective interventions, the increase is projected to rise to 570.9 million prevalence, 1.59 million mortality, and 79.3 million disability-adjusted life years. [1] According to the International Diabetes Federation Diabetes Atlas (2021), 537 million adults aged 20 to 79 currently have diabetes. This number is estimated to increase by 46% between 2021 and 2045. Projections of the prevalence of adults with DM worldwide in 2030 and 2045 are 643 and 783 million, respectively. [2] High glucose levels in patients with DM are caused by a lack of insulin production or conditions, thereby impeding the transfer of glucose in the blood into the cells. T2DM is associated with pancreatic β-cell dysfunction coupled with some degree of insulin resistance. Dysfunctional β-cells are unable to adjust the quantity of secreted insulin required to maintain normal plasma glucose levels. [3] Therefore, a high level of blood glucose is a sign of DM. [4] Hence, one of the main treatment goals is to maintain stable blood glucose values. The therapy generally comprises oral medications (e.g., biguanides, first-and second-generation sulfonylureas, meglitinides, or sodium-glucose cotransporter-2 inhibitors), non-insulin injections, or insulin injections that are administered to improve insulin deficiency or impaired insulin conditions. [3] Non-pharmacological interventions, such as a modified diet, weight control, regular exercise, physical activity, and bariatric surgery, can also be part of the treatment. [5] Patients who are beginning their therapy require counseling regarding their treatment. After beginning medication, they require regular monitoring. Therefore, it is important to understand the latest and most effective counseling approaches that can be used to treat patients with DM.
Counseling is a professional activity that entails helping clients individually or in groups, or as couples and families, deal with various problems. It is practiced by counselors, psychiatric nurses, psychologists, physicians, pharmacists, and other health care teams. These professionals play a vital role in assisting patients and their families to adjust to chronic illness and assess quality-of-life (QoL) issues related to the disease by educating and advising them regarding adherence to their medication regimens and monitoring plans, thus monitoring their therapy outcomes. [6] Healthcare teams may cooperate in formulating a specific package of information and advice targeting the individual's care requirements. Such coordinated efforts of health care teams result in improved patient compliance with their medication regimens, more effective drug efficacy monitoring, and the receipt of feedback. [7] Currently, patients with chronic illnesses mainly receive primary care and are trained in self-management. This approach is critical for patients to achieve their personal health goals and communicate effectively with health care practitioners. [8] DM counseling includes monitoring related outcomes such as glycated hemoglobin A (HbA 1c ) levels, daily self-care, and other issues such as blood glucose measurement and compliance with diet, exercise, and medication regimens. [9] Digital approaches, such as teleconsultations, telehealth, or telemedicine, provide solutions for optimizing DM patients' management of their symptoms and their exacerbation in contexts of restricted contact and inability to access care in person. [10] Patients can communicate and discuss their situations with health workers, who can help them to maintain their self-management regimes using smartphone apps. Their physicians can help them choose suitable types of physical activity and provide guidance on staying physically active by sharing illustrative exercise videos. Physicians or DM educators can also ensure drug compliance, help patients procure their medication, and educate them on how to cope with a hypoglycemic crisis via online consultations. Patients can also have discussions with nutritionists on how to maintain a healthy diet and order the glucose strips online after consulting pharmacists. [11] A study by Röhling et al [12] showed that a telemedicine-based system combined with an approach involving a team of healthcare professionals could be successfully implemented in an inpatient setting and directly improve the quality of care.
Previously published systematic review papers analyzed telemedicine's effectiveness in managing T2DM, showed a significant reduction in HbA 1c and had impacts on secondary outcomes such as mental and physical QoL compared to the control group. [12][13][14] This evidence motivated us to explore telemedicine counseling strategy in DM management further. [14] We also assessed patients' adherence as the secondary outcome, which has not been assessed in other reviews. We tried to apply the results to the current counseling technique used in the ongoing coronavirus disease 2019 (COVID-19) pandemic, particularly by professional healthcare in Indonesia.
Telemedicine has emerged as an essential digital platform for implementing this approach, particularly during COVID-19, which has compelled health centers to limit in-person clinical visits to prevent the spread of the virus. The governments of various countries have also launched measures to control the spread of infection, such as lockdowns, quarantine, and social distancing. [15] The likely effects of lockdowns and social distancing on DM patients would have been little physical activity, necessary changes in their dietary habits because of restrictions in food supplies, and difficulties in obtaining their anti-diabetic medication and glucose strips. Moreover, they would have been unable to see their physicians in person to receive regular advice and follow-up care at the clinics. This situation has thus transformed DM management into self-management practices, and the method by which healthcare providers and DM patients communicate has become virtual. [11] We tried to make up the newest studies analysis in the recent 10 years as there was a similar systematic review and meta-analysis with studies ranging from 20 years before. Adding a telemedicine approach to conventional or face-to-face T2DM disease management strategies resulted in a slight decrease in HbA 1c . We believe that in the face of this pandemic, all healthcare providers are willing to work toward resolving the issues that arise in the service of their patients. This narrative review was conducted to help healthcare professionals provide the best possible health services for DM patients and to consider an optimal counseling approach that could be applied during the ongoing COVID-19 pandemic, which restricts face-to-face meetings. Accordingly, we evaluated the effectiveness of telemedicine as a counseling tool for patients with DM, considering blood glucose levels as the primary outcome.

Ethical statements
No ethical approval was necessary for this study because it was a literature-based study. This review was conducted following the Scale for the Assessment of Narrative Review Articles (SANRA). [16]

Design
Besides the SANRA guideline, [16] this narrative review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of 2020. [17] A literature review is described as published materials that provide an examination of recent or current literature. which can cover a wide range of subjects at various levels of completeness and comprehensiveness and may include research findings. [18] According to Sutton et al, [19] a narrative review is defined as a legacy model of a review criticized during the early years of the systematic review movement because of its lack of transparency, and a narrative review serves a continuing role when performed more systematically in orienting research into a broader field.
We did not perform a partial systematic review and meta-analysis owing to time constraints and the limited number of articles available for analysis. We conducted a panel discussion to enable us to complete the quality assessment.

Search strategy and study eligibility
We conducted a literature search by title and abstract in the EBSCO, Embase, PubMed, and Web of Science electronic databases from October to November 2021. In line with the Patients, Intervention, Comparator, and Outcomes search strategy, we applied the following keywords: "diabetes mellitus" AND "telemedicine" AND "counseling" AND "glucose level." Randomized controlled trials (RCTs) performed to determine and correlate the effectiveness of telemedicine and conventional counseling for patients with DM were included in the review. We only included full-text articles published in English in the last 10 years. In both telemedicine and traditional in-person contexts, counseling was defined as monitoring treatment and explaining the following aspects to patients: control and measurement of blood glucose levels, information on medication, monitoring of therapy, and health management.

Study selection
Three reviewers and a principal investigator (PI) searched electronic databases. Next, the reviewers screened the titles and abstracts and independently screened the full texts of potentially eligible articles. Disagreements regarding the study design, intervention criteria, and outcome measures were resolved through discussion.

Data extraction and summarized
The 3 reviewers extracted the data independently and checked it by the PI. The reviewers resolved any disagreements through discussion and consultation with the PI. The following data were extracted from the included articles: name(s) of the author(s) and year of publication, location and time of the study, total number of participants in the control and intervention groups, types of telemedicine used, primary and secondary outcome measures, study results, and conclusions.

Search results
The search of electronic databases yielded 132 articles. After eliminating duplicate articles, 129 remained. After screening the titles and abstracts, 12 articles remained. Finally, 3 studies were excluded because they did not meet the inclusion criteria. In total, we have 9 articles assessed in this review. Figure 1 depicts the process used to select the articles. Table 1 provides a detailed summary of the articles included in the review. The studies in the articles were conducted in South Korea, [20,27] the United States, [21] Australia, [22] Norway, [23,24] Greece, [25] Israel, [26] and Bangladesh. [28] The date range for the studies was 2007 to 2020.

Characteristics of the included studies
Nine RCTs were analyzed, encompassing a total of 962 participants. The age range for the intervention and control categories of the participants was 18 to 80 years. The primary outcomes measured and reviewed were blood glucose levels or HbA 1c , QoL, [23,24] and patient compliance. [22,[25][26][27][28] The duration of the studies ranged between 3 months [20,21,25] and 1 year. [24] 3. 3

. Intervention
The selected studies reviewed the effectiveness of telemedicine as a tool for counseling using conventional counseling as a control. They covered the following topics: pharmacological treatment and therapy, monitoring of therapy outcomes (self-monitoring and joint monitoring with practitioners), monitoring of patients' treatment adherence, QoL, their activities, and their feedback on their health. The patients' questions were also considered.

Outcome measures
One of the 9 RCT studies measured HbA 1c , fasting plasma glucose (FPG), and 2-hour post-meal glucose (2HPMG) levels. [20] Another study measured body mass index (BMI), exercise, diet, DM symptoms, foot care, depressive symptoms, and therapeutic mechanisms but did not measure significant HbA 1c levels. [21] In a third study, a home-based exercise program was the primary outcome, and peak oxygen consumption, HbA 1c (%), and QoL were secondary outcomes. [22] Using similar methods, 2 studies [23,24] focused on HbA 1c levels as the primary outcome, with behavioral changes (physical activity and diet), self-management, and patients' health-QoL as the secondary outcomes. [23] In addition to symptoms of depression, lifestyle changes (physical activity and dietary habits) were considered in the study. [24]   Two other studies used blood glucose levels as the main measurement. [25,28] The first study's outcomes were morning (fasting), preprandial, and postprandial glucose levels. The outcome measures in the second study were related to the frequency of hospital visits and medication intake adherence combined with a dietary approach, physical exercise, betel nut consumption, tobacco control, and blood glucose control. One study used the actual blood glucose measurement (percentage) as an outcome. [26] Only 1 study measured outcomes related to gestational diabetes: obstetrical outcomes (gestational age at delivery and birth weight), and metabolic outcomes (BMI, weight, percentage of body fat, insulin resistance, and HbA 1c ). [27] 3.5. Effectiveness of telemedicine counseling Table 2 summarizes the data extracted from these studies. All the included studies evaluated the effectiveness of telemedicine counseling compared with counseling in the control groups using HbA 1c levels. Five of the 9 studies reported that telemedicine counseling was more effective in decreasing HbA 1c levels in diabetic individuals than the results of conventional counseling applied to the control group. [20,[25][26][27][28] However, 1 study did not report HbA 1c results . [21] Two studies reported that telemedicine counseling did not significantly improve HbA 1c levels, and patients that received usual care had better results. [22,23] Furthermore, although HbA 1c levels did not decrease significantly, 1 study reported that the results of telemedicine with health counseling offered by a DM specialist were more significant concerning patients' treatment, medication adherence, and QoL. [24] Six of the 9 studies also assessed other parameters related to patients' compliance and QoL. They all reported that telemedicine increased these parameters in patients with DM.

Discussion
The supplementary data depicts the result of SANRA guideline [16] assessment, http://links.lww.com/MD/I42. All 9 studies assessed have SANRA scores equal to or above 10. The study by Torbjørnsen et al, [23] Holmen et al, [24] and Sung et al [27] had the highest SANRA score of 12. Nine studies were analyzed for the intervention of telemedicine counseling applied in each study related to DM management.
This review compared current evidence from recent studies on the effects of telemedicine counseling and conventional (faceto-face) counseling in patients with DM using glucose levels as the outcome measure. To the best of our knowledge, a review of RCTs comparing telemedicine counseling and conventional (face-to-face) counseling in patients with DM using glucose levels as the outcome measure has not been performed. Thus, the objective of this review was to evaluate the effectiveness of counseling methods in patients with DM. This finding showed that counseling and monitoring patients with DM via telemedicine were more effective than conventional counseling.
Five of the 9 studies reported positive results regarding the effectiveness of telemedicine. For instance, in a study by Kim, [20] the FPG value decreased. In contrast, the HbA 1C and 2HPMG values decreased significantly for patients in the intervention group who received counseling on DM treatment and monitoring. In contrast, the values for all outcomes in the control group increased, rather than decreased, after 12 weeks. Patients in the intervention group contacted nurses more frequently than those in the control group received advice based on the latest data, and they confirmed that their present condition could explain this finding. Consequently, they might have been more motivated to control their glucose levels. However, despite the decrease in FPG and 2HPMG levels in the intervention group, most patients did not reach the target FPG and 2HPMG levels. This result may be attributed to the short study duration. Nonetheless, this study found that telemedicine was effective.
Kotsani et al [25] also found that the mean glucose level (morning, preprandial, and postprandial blood glucose) and the mean HbA 1c level of the experimental group was significantly reduced compared with those in the nonintervention group. After 3 months of study, the values for all outcomes showed good progress in the intervention group. The HbA 1c level decreased by 0.5% in the intervention group compared with the 0.2% decrease in the control group.
Miremberg et al [26] found that patients in the intervention group had better compliance values than those in the control group. This result affected other outcome parameters such as mean blood glucose level, insulin treatment rate, off-target insulin rate, and the 1-hour postprandial blood glucose level. Consequently, the values of these parameters were improved. The patients' compliance values were calculated as the actual blood glucose measurements/instructed measurements multiplied by 100.
Sung et al, [27] who studied gestational DM patients, also found that patients in the intervention group had better post-delivery metabolic outcomes than those in the control group. This result may be attributed to their receipt of regular, twice-weekly messages, communication with healthcare providers, and adherence to dietary and exercise recommendations. The control group communicated only with the healthcare providers when they visited the clinic.
Yasmin et al [28] also found that mobile healthcare positively affected the intervention group. This group obtained better results for blood glucose levels 2 hours after breakfast and fasting blood glucose than the control group. These positive results could be because the intervention group received interactive voice calls every Friday, every 10 days, and on national holidays. Patients could also access a physician and obtain counseling by contacting 24/7 call center services. These callbased interactions supported them through recommendations related to hospital visits, medications, physical exercise, diet, and other lifestyle modifications. The patients also received reminders notifying them when their hospital visits were scheduled. These interactions positively affected medication adherence and hospital visits, although some patients abandoned their medication and hospital visits because of financial constraints.
However, 3 studies reported that telemedicine did not significantly improve HbA 1c levels. The study by Marios et al [22] showed that patients who were instructed to exercise for 180 minutes per week and were given counseling telephonically did not demonstrate significant decreases in blood glucose levels, even though the mean exercise duration for the intervention group was 138 minutes. By contrast, the control group showed better results since more than 138 minutes of exercise per week or more than 1392 (kcal) of energy expended through weekly exercise are required to achieve improved glycemic control. The findings of this study are consistent with the guidelines of the American Heart Association, which state that a minimum weekly exercise routine amounting to 150 minutes of moderately intense or 90 minutes of high-intensity activity is required to improve glycemic control. However, examination of other outcomes showed that the intervention group had better results for maximum oxygen consumption, exercise (treadmill) test time, and maximum heart rate.
In addition, Torbjørnsen et al [23] indicate that telemedicine may not be sufficiently effective in decreasing HbA 1c levels. In this study, there were 2 intervention groups: in 1 group, the Few Touch Application (FTA) was applied, and in the other, FTA with health counseling (FTA-HC) was applied. In both groups, the blood glucose levels remained high and did not show a rapid decrease. FTA intervention may have been too time-consuming, especially for the FTA-HC group. The availability of new software could have enhanced the ability of participants to influence Medicine the results, thereby changing the intervention. The use of apps and health counseling in the experimental group did not reduce HbA 1c levels as the primary outcome relative to this outcome in the nonintervention group. However, utilization of the app improved the participants' skills in navigating self-management of health care and symptom relief, with or without additional health counseling. Holmen et al [24] found that HbA 1c levels were reduced in all intervention groups under similar conditions. However, the changes observed in the different groups after 1 year did not differ significantly. Nevertheless, for secondary outcomes, there were significant changes in self-management and lifestyle in the FTA-HC intervention group. Individuals in this group demonstrated enhanced skills related to technical aids and were sufficiently able to reduce symptoms and manage their health effectively. This improvement is an essential requirement for the daily self-management of DM. It is also reasonable to assume that if self-administered interventions improve HbA 1c levels, they must entail healthy eating, adequate physical activity, and medication adherence. Therefore, it can be concluded that the FTA-HC intervention, which included health counseling with DM specialists, led to more improvements in self-management HbA 1c target in Norway is ≤7.0% Self-management (Health Education Impact Questionnaire, heiQ), behavioral change (these were diet and physical activity), also health-related quality of life (SF-36) questionnaire The FTA intervention may have taken too long, also even more for the FTA-HC group. There was also a limitation of a more significant opportunity for the participants to influence the results. The mean decrease change of HbA 1c in the FTA group is 0.23, while the mean change of HbA 1c in the FTA-HC group is 0.41, and for the control group who received usual care is 0. HbA 1c levels decreased in all groups, but there was no significant difference in changes after 1 year. However; in these 3 groups, the mean HbA 1c level did not increase to the baseline level It was shown that there was a significant change in self-management in the FTA-HC group, as they alleviated symptoms and improved their ability to manage their health effectively, also better skills in using technical aids Although there is no significant HbA 1c level difference, The FTA-HC with diabetes specialists were indicated to be more effective in their health-self management. and reducing patients' symptoms 6.
Kotsani K et al (2018) [25] Patients in the intervention group were asked to write down their glucose values in a diary and submit them in 3 ways: via USB connected to a glucose meter, email, or phone call. This group is contacted by telephone every Thursday (10-12 am) for 5-15 min by the nurse-coordinator, discussing possible problems in their disease management and some recommendations based on the data they input Patients in the control group were asked to write down their glucose values in a diary. The researchers advised patients to submit their data either via USB connected to a glucose meter or by email or collect them to be reviewed at the end of the study. No interaction over the telephone is done in the control group There has been a significant improvement in the glucose level in the intervention group Although the method used by Sacco et al [21] was almost the same as that used in other studies, their results differed. They did not find a significant effect on HbA 1c levels or BMI. In this study, the intervention group had weekly telephonic coaching sessions  with a DM coach, each lasting 15 to 20 minutes for the first 3 months, and subsequently had fortnightly sessions during the last 3 months. The reason for not measuring HbA 1C levels and BMI significantly was that significant effects were observed only on valid face self-report measures. Positive outcomes could reflect a response bias. In addition, it may be unreasonable to expect a high level of reduction in HbA 1c and BMI, given the brevity of the sessions and the semi-structured nature of coaching calls. However, this study showed significant positive effects on patients' diabetes-related self-efficacy, adherence to self-care activities (e.g., diet, physical exercise, and foot care), and awareness of self-care goals. They also showed decreased depressive and DM symptoms.
Most studies found that telemedicine counseling improved the quality of counseling methods for DM patients and led to decreased blood glucose levels, higher medication and treatment adherence levels, and a better QoL among patients. One study found that telemedicine and health counseling by DM specialists led to improved QoL and self-care management among recipients. [24] In this study, we focused only on DM management. However, telemedicine counseling positively affected the outcomes of other diseases and hypertension management. A review by Hoffer-Hawlik et al [29] demonstrated that technologies imparted through telemedicine for hypertension management significantly affected blood pressure outcomes in most 14 low-and middle-income countries studies. These findings are consistent with previous reviews on telemedicine interventions for hypertension control in high-income countries. For example, an overall summary was carried out by Wang et al, [30] estimated that there was an improvement in clinical blood pressure control.
Although telemedicine has proven advantageous in disease management, it also has a few disadvantages, such as the absence of a physical examination by healthcare experts. The weakness of telemedicine causes difficulties in diagnosis in a virtual clinic. Furthermore, most patients are older individuals with limited technological skills, some of whom do not know how to access telemedicine or may even be unaware of this treatment option. [31]

Conclusion
Most of the studies included in the review found that counseling applied in a telemedicine context was more effective than the conventional counseling method. A critical review finding was decreased blood glucose levels, increased treatment and medication adherence, and improved QoL among patients with DM. In light of the findings of 1 of these studies, a combination of telemedicine and conventional counseling with more health counseling provided by DM specialists could be considered. This approach will increase patient knowledge and enable healthcare providers to provide routine supervision. Data analysis is facilitated by using specific apps and electronic health recordings. Finally, patients can be monitored at home without visiting the clinic, avoiding face-to-face contact, following the "new normal" in the COVID-19 pandemic context.

Strengths and limitations
Although the narrative review yielded 9 studies, and several limitations are associated with the methodology used. First, a simple panel discussion was conducted among the authors to assess the quality of the articles, and the risk of bias was not considered. These conditions may have undermined the validity of the findings and led to errors. Second, the search for existing studies may not have been sufficiently comprehensive; we searched only 3 databases due to time limitations so some articles might have been missed. Third, some articles or references may have been missed because of Medical Subject Headings terms or keywords. We also limited our search to include only studies conducted in English; therefore, this might have led to missing relevant studies in other languages. We conducted a narrative review because we wrote this paper after winning the Center of Excellence in Higher Education for Pharmaceutical Care Innovation competition, Universitas Padjadjaran, Bandung, Indonesia, and were restricted by time constraints. More research is needed to investigate further the points and themes raised in this study.
Consequently, we conducted a meta-analysis as a follow-up study. However, we attempted to address these gaps by following the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines when conducting the literature search. The strength of this study relates to the adherence of DM patients to the current RCT studies.

Clinical implications
The findings of this review indicate that telemedicine counseling may be effective for patients with diseases, such as DM, that require long-term therapies for their management. They suggest that implementing a combined (hybrid) counseling method, entailing a mix of conventional (face-to-face) and telemedicine counseling in countries such as Indonesia, is appropriate and efficient in the current context of the COVID-19 pandemic.